Reimbursing Chronic Care Management (CCM)
Wednesday, October 29th, 2014
Disclaimer: Nothing that we are sharing is intended as legally binding or prescriptive advice. This
presentation is a synthesis of publically available information and best practices.
The concept has always sounded simple; reduce
costs and improve care.
It’s been proven that Care Management of chronic disease
accomplishes both, so why were Care Management programs
Lack of Payment
• Most payers bundle payment for non-face-to-face
• Care Management limitations in PM systems and
integrated tools were lacking
Is there any clearer message?
CMS will be reimbursing providers for Care Management services Effective
January 1, 2015.
CMS acknowledged that 75% of our healthcare spending is directly related to
chronic conditions. It sends a clear message that the costs associated with
chronic disease drives the decision to encourage care management in our
Often times, the following items below were viewed as
bundled into the E&M codes. It has since been recognized
that the items were under valued and an important part of
the care management of the patient:
Work that includes answering patient phone messages
Work that includes answering patient electronic messages
Sorting through formulary changes
Responding to labs or consultation recommendations
Providing weekend coverage.
Providing night emergency coverage
No Longer Bundled
• When billed with the following services:
• Separate payment for non-face-to-face chronic care management
services for Medicare beneficiaries
• When Billed with the following services:
• Home Health
• Nursing Home
• Medicare patient
• Expected to live 12 months or until death
• Multiple, significant chronic conditions (two or more)
• Roughly $42.00
• Subject to Co-Payment
• Time Based- 20 Min
• HCPCS Code to be released in November
• Once per month, per qualified patient provided that medical
needs of the patient involve the following as it relates to the
Documentation in the patient’s medical record that all of the
chronic care management services were explained and
accepted by the patient
• Document Time and Service Provided
A written agreement that electronic communication of the
patient’s information with other treating providers is part of
Information about the availability of the services from the
A written or electronic copy of the care plan that is provided to
the beneficiary and recorded in the electronic health record
Though it’s anticipated that there will be additional
requirements forthcoming, the list below are identified as
expectations for CCM:
Continuity of care with a clinician or practice
Care management that provides the following:
• A systematic assessment of medical, functional,
and psychosocial needs
• A system-based approach for timely delivery of
• Medication reconciliation
• prescription and nonprescription
• review of interactions and adherence
The creation of an updatable patient-centered plan of care
Management of all care transitions
An EHR that is available 24/7 to both the the caregiver as well as
Opportunities for patient-to provider communication via
telephone or secure asynchronous NF2F messaging
Where do you begin?
Identify patients that meet the minimum criteria
Begin the communication
Establish your written protocols
Identify the appropriate staff who comprise your clinical care
Pursue PCMH designation
Establish your strategy
Years ago, physicians disagreed with this statement. They insisted that caring for the patient was the top priority. Many have learned that have to be profitable to keep the doors open. It is the only way to continue to care for patients. Healthcare reform, New Coding System, and lack of ability for patients to pay medical expenses challenge practice profits.
If you are disciplined in managing the cycle, it can get that close to the perfect scenario.
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